It got buried beneath an avalanche of Obamacare scrutiny and anti-Obamacare spin, but the most revealing statement about the future of the Affordable Care Act yesterday came in the form of a flustered conversation between a CNN host and Rep. Renee Ellmers, R-N.C.
If you have nine minutes to spare, I recommend you watch the whole thing. But here's the short version.
An unusual arrangement in the commonwealth of Kentucky gave Democratic Gov. Steve Beshear the power to implement the Affordable Care Act almost by fiat. And he did it. The ironic consequence is that one of the most conservative states in the country, surrounded by states that have by and large tried to obstruct the law, now has one of its best functioning insurance exchanges, Kynect.
Because it was developed independently from Healthcare.gov -- and because Beshear's administration took great care to make the law work for skeptical constituents -- Kynect customers seem to be happy and are signing up by the thousands.
Ellmers' North Carolina doesn't share a border with Kentucky but it's safe to call it a neighboring state. Its population as a whole is less conservative than Kentucky's, but it's governed by conservative hard-liners. So it's no surprise that Ellmers hates Obamacare and uses Healthcare.gov's inauspicious launch to bolster the case that it should be repealed.
What's revealing is that when asked to contend with Obamacare's relative success across a couple of borders in Kentucky, she plunges into gibberish. She can't even begin to grapple with it.
Her reaction is a harbinger of future Obamacare politics if the administration can't make Healthcare.gov work and the insurance markets in states with federally administered exchanges begin to fail.
I suppose it's possible that if Obamacare fails in states that ceded the power to build their own exchanges, the legislative coalition shielding the law would begin to splinter. Doubtful. But we are talking 34 states, only a few of which are politically amenable to fixing it.
That would leave the U.S. healthcare system with a murky future.
On the other side of that coin, 14 states -- Kentucky among them, but also large-population states like California and New York -- are doing Obamacare as its authors envisioned. If, in a worst-case scenario, Obamacare is completely dysfunctional everywhere else next year, these states will still create a constituency of millions of people for the law right out the gate.
That will help immunize it from legislative mischief. But it'll also put legions of Republicans in the same position Ellmers found herself in on Tuesday -- forced to confront the reality that the law only isn't working for people whose states begged off the project, or undermined it intentionally. Many people living in those states will know that things would be better if only their elected leaders would just make their peace with Obamacare and make their own constituents' lives better by implementing it.
So what will happen? Well, first, I hope that the administration gets Healthcare.gov working and that people are ultimately able to enroll successfully wherever they live. As much as a small part of me (small, but bigger than I'd like to admit) thinks the reactionary leaders of these states are reaping what they've sown and should live with the consequences of their opportunistic abandonment of their phony commitment to states' rights, it would be better for everyone and better for liberalism for the administration to figure this out, soon. It'll also limit the long-term political damage to the law, and reduce the odds that Republican saboteurs in Congress ultimately get their way.
But if that doesn't happen, the night and day contrast between consumer experiences in states like Kentucky and North Carolina, or New York and New Jersey, will create new tensions between Republican governors and the activist right.
It turns out the politics of Obamacare will become much more interesting if Healthcare.gov never gets off the ground.
We're already seeing a similar dynamic play out in states as diverse as Arizona, Ohio and New Jersey, where Republican governors -- once conservative standard bearers, now fallen RINOs -- transgressed against their bases and agreed to implement the ACA's Medicaid expansion. The most important ACA news of the week had nothing to do with Healthcare.gov. It was that Ohio's Republican Gov. John Kasich circumvented the state Legislature to expand Medicaid, opening the program to about 300,000 new low-income beneficiaries.
The optimistic scenario -- well, the optimistic sub-scenario, if the federally facilitated marketplaces fail -- is that states without their own exchanges fall like dominoes and begin building them.
Perhaps a likelier scenario is that a dozen or so blue and purple states, plus a handful of red ones, would follow California and Kentucky's lead and go the states' rights way. Why wouldn't Chris Christie run to the rescue of New Jerseyans suffering under the yoke of federal overreach? Or Kasich. Or even Jan Brewer, who probably can't run for reelection anyhow, and already steamrolled the Arizona Legislature to expand Medicaid? The holdouts would largely be revanchist Southerners, bent upon pitting the most dubious of principles against their own interests.
That would leave the U.S. for a time with a bizarre, two-tiered healthcare system. One, for most people, that would work pretty well. Another highly dysfunctional one for post-policy conservatives, which would either last until the feds get it right, or slowly shrink over time as states recognized how pointless the stand they were taking really was.